Introduction: We present a case of a 65 year-old female with cT3b renal cell carcinoma (RCC) and inferior vena cava (IVC) tumor thrombus who underwent open right partial nephrectomy (PN) with IVC thrombectomy at our institution.
Methods: 65 year-old female with CKD stage III [baseline estimated Glomerular Filtration Rate (eGFR) 57 ml/min.1.73m2]and active segmental pulmonary emboli (PE) presented with locally advanced RCC with venous tumor extension to the level of the intrahepatic IVC. Patient was deemed to not be optimal surgical candidate due to symptomatic PE and poor performance status (ECOG 2 status) and also had strong indication for nephron preservation. The patient ultimately underwent systemic therapy with 12 cycles of nivolumab and 6 cycles of ipilimumab with shrinkage of primary tumor and regression of tumor thrombus to the infrahepatic IVC.
Results: Open right PN with IVC thrombectomy was undertaken. A reverse-hockey stick incision was made. Large and small intestinal medial reflection was conducted with liver mobilization. Cranial and caudal IVC control was obtained as well as control of the contralateral renal vein. IVC clamping and control of the contralateral renal vein in addition to clamping of the main renal artery was conducted, and the tumor and IVC tumor extension were resected en bloc via a venotomy and longitudinal cavotomy, primary closure of which were performed with 6-0 and 3-0 Prolene. Collecting system entries and segmental vessels were closed with 3-0 Monocryl and 4-0 PDS. The cortical defect was then approximated with 0 Chromic suture and hemostatic agents.
Final pathology demonstrated pT3b clear cell RCC/ISUP grade 2 with protrusion into IVC. Negative margins for primary tumor and distal caval margins. Postoperative creatinine was 1.01 ng/dL with eGFR of 55 mL/min/1.73m2. No evidence of disease was noted at 3-month radiologic follow up.
Conclusions: PN with IVC thrombectomy may be safely achieved for select patient with imperative indication for nephron sparing surgery. Further investigation of long-term oncologic outcomes and efficacy are requisite.
Source of Funding: Stephen Weissman Kidney Cancer Research Fund